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A Time for Change: Nutrition Education in Medicine

The New England Journal of Medicine recently published an article entitled “Simulation of Growth Trajectories of Childhood Obesity into Adulthood.” The models in the study projected that 57.3% of today’s children will be obese by age 35.1 The bleak predictions of future health trends such as these reaffirm the need for health professionals to be knowledgeable about nutrition.

Patients expect physicians to be sources of information related to nutrition. In fact, 61% of respondents to an American Dietetic Association (now the Academy of Nutrition and Dietetics) survey stated that they believe physicians are a “very credible” source of nutrition information.2 At the same time, though, in a study of internal medicine interns, 86% of respondents admitted to being inadequately trained to provide nutritional counseling. This inadequacy starts early in a physician’s career, with 51.1% of medical school graduates in 2005 reporting that they received insufficient nutrition education during medical school.3

Take the field of cardiology, for example, where a recent study found that, among a cohort of 930 cardiologists, 90% believe their role includes providing patients with basic nutrition information. In the same group of physicians, though, 90% stated that they had received little-to-no training in nutrition during their fellowship, 59% stated that they had received no nutrition during internal medicine training, and 31% reported no nutrition education in medical school.4 Simply put, the perceived role of physicians and the training they are given don’t match up.

This is not a matter of self-reported opinion either, because curricula also lack dedicated nutrition training, and this is not a new phenomenon. In 1962, the American Medical Association (AMA)’s Council on Foods and Nutrition held a conference pertaining to the “inadequate recognition, support and attention” given to nutrition education in medical schools. The council acknowledged that nutrition is intimately involved in the pathogenesis of chronic and degenerative diseases and that the medical curriculum was lagging with respect to advances in nutrition science. 5 The interrelatedness of medicine and nutrition was recognized by the council as more than the just the treatment of isolated nutrient deficiencies.

In 1976, the AMA conducted a mail survey to better understand the status of nutrition education in U.S. medical schools. When 102 medical schools responded to the surveys, fewer than 20% of schools reported requiring a nutrition course.6 The schools cited lack of funds, inadequate number of physicians trained in clinical nutrition, and limited amount of time available in the curriculum as limitations for increased nutrition education. This forty-year-old survey also highlighted the increased interest in nutrition from students and faculty at these institutions.7 We can only assume this interest has since grown.

The scientific conferences and congressional hearings in the decades leading up to the 80s drew attention to the need to improve nutrition education in U.S. medical schools. As a result, the National Research Council Committee on Nutrition in Medical Education published recommendations in 1985 stating that a minimum of 25 to 30 classroom hours during preclinical years should be allotted to covering the topics in nutrition that were underscored by the committee.6 For the past two decades, research spearheaded by University of North Carolina at Chapel Hill has tracked the state of nutrition education in U.S. medical schools every four years. Unfortunately, the data show no sign of changes in the average hours required in nutrition education since 2000. The most recent survey during the 2012-2013 academic year included 121 medical schools, with an average of 19 hours (SD =13.7) of nutrition education in their curriculum. The survey showed that 71% of medical schools failed to meet the minimum recommendation of 25 hours, 36% provided 12 or fewer hours, and 9% provided none.8

Current nutrition education is evidently not translating into practice when only 10% of primary care physicians include weight counseling for patients, and fewer than half of obese and overweight patients are advised to lose weight.9 Primary care practitioners overwhelmingly support requiring additional training so that they will be better informed about the care they provide to their patients with obesity.10

The Association of American Medical Colleges has recently declined to incorporate nutrition into its new blueprint for medical competencies.11 The 2013 American Council for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education in Cardiovascular Disease neglects to mention nutrition. 12 This continues to be the case in the most recent iteration of the ACGME requirements along with the ACGME for Internal Medicine.13,14 These examples show that both medical schools and graduate medical education have yet to legitimize the value of incorporating nutrition training through their competencies.

Three programs that have become recognized for their innovative approach to nutrition curriculum at medical schools include:

  1. The Nutrition in Medicine (NIM) Project – since 1995 this program has aided in the development and distribution of nutrition curriculum for medical students through comprehensive online courses free of charge. The curriculum is a 29-unit curriculum covering basic science content along with clinical applications through cases. About 50% of medical schools actively use the NIM curriculum and the flexibility of the curriculum has allowed for varied implementation at these schools .15 A more recent initiative by the NIM team is the Nutrition Education for Practicing Physicians for residents, fellows, and practicing physicians. These online modules differ from the medical school resources through the greater level of clinical detail and practical applications (http://www.nutritioninmedicine.org/).
  2. Healthy Kitchens, Healthy Lives – The Culinary Institute of America and the Harvard T.H. Chan School of Public Health have collaborated as a strategy to enhance physician ability and motivation for nutrition counseling through interactive cooking experiences. The program uses teaching kitchens to demonstrates how nutrition science can be translated into nutritious meals. This initiative has shown to be successful in changing physicians’ dietary practices and their inclination to offer nutrition counseling at a 3-month follow-up.16 Currently, over 6,000 health professionals have taken the course. This initiative has expanded to 32 organizations located in 16 different states, plus Italy and Japan. The kitchens are active in universities, hospitals, and corporate buildings. (http://www.healthykitchens.org/)
  3. Tulane University School of Medicine’s Goldring Center for Culinary Medicine – this is the first teaching kitchen implemented at a medical school. The center trains medical students and professionals through culinary medicine classes in the form of electives and seminars as well as continuing education. The idea is grounded in the idea that the knowledge to cook nutritious meals encourages patients to buy vegetables and fruits that they previously avoided because they didn’t know how to prepare them. Tulane offers an institutional and away rotation at Johnson & Whales University in Providence Rhode Island where students can participate in hands-on culinary and culinary nutrition classes as well as an academic research project related to medical nutrition therapy. Medical students can also opt to take an 8-class culinary medicine elective during their first or second year of school. (https://culinarymedicine.org/)

The physician is the head of the care team and is responsible for directing care and allocating personnel and resources. Physicians see many patients when they are most in need of nutrition guidance. Therefore, physicians should be able to assess and recognize nutrition-related problems, and appropriately coordinate patient care. Let us hope that these programs are increasingly adopted in medical education so that physicians will be better equipped to address the health of their patients.

 

References:

  1. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153. doi:10.1056/NEJMoa1703860.
  2. Nutrition and You: Trends 2008.; 2008. http://www.eatrightpro.org/~/media/eatrightpro files/media/trends and reviews/nutrition and you/trends_2008_are_you_already_doing_it.ashx. Accessed November 30, 2017.
  3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27(2):287-298. http://www.ncbi.nlm.nih.gov/pubmed/18689561. Accessed November 30, 2017.
  4. Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-1305. doi:10.1016/j.amjmed.2017.04.043.
  5. Council on Foods and Nutrition. JAMA. 1963;183(11):955. doi:10.1001/jama.1963.03700110087015.
  6. National Research Council (US) Committee on Nutrition in Medical Education. Nutrition Education in U.S. Medical Schools. Washington, DC; 1985. doi:10.1007/BF02427708.
  7. Cyborski CK. Nutrition content in medical curricula. J Nutr Educ. 1977;9(1):17-18. doi:10.1016/S0022-3182(77)80110-6.
  8. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. J Biomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627.
  9. Kraschnewski JL, Sciamanna CN, Pollak KI, Stuckey HL, Sherwood NE. The epidemiology of weight counseling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37(5):751-753. doi:10.1038/ijo.2012.113.
  10. Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871. doi:10.1136/bmjopen-2012-001871.
  11. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013;88(8):1088-1094. doi:10.1097/ACM.0b013e31829a3b2b.
  12. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003.
  13. ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_2017-07-01.pdf. Accessed November 30, 2017.
  14. ACGME Program Requirements for Graduate Medical Education in Internal Medicine.; 2017. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed November 30, 2017.
  15. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-480. doi:10.1177/0884533610379606.
  16. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing Medical Education to Address Obesity: “See One. Taste One. Cook One. Teach One.” JAMA Intern Med. 2013;173(6):470. doi:10.1001/jamainternmed.2013.2517.

 

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Health Professionals Need More Nutrition Education. How Can We Deliver?

By Allison Dostal, PhD

It’s not a revelation that most Americans would benefit from increased nutrition education and guidance. Newly released data from the Centers for Disease Control and Prevention1 show that 64% of Americans are overweight or obese – a number that’s held steady over the past few decades – and that nearly 40% of us consume less than 1 serving of fruits or vegetables daily. $210 billion is spent annually on obesity-related disease2.

It is known, perhaps intuitively, that physicians trained in nutrition achieve improved health outcomes in patients with obesity-related conditions3. Numerous clinical guidelines recommend that physicians counsel their overweight and obese patients on diet, and yet, fewer than 25% feel that they received adequate training in doing so. As a result, only 1 in 8 medical visits includes a discussion of nutrition4,5. This disconnect in recommendations versus practice is a significant issue in medical education today, and the perennial discussion of how to improve the current state of nutrition education in the medical curriculum continues to increase in relevance in our nation’s obesity crisis.

The Problem

It is recommended that physicians-in-training receive 25 contact hours of nutrition education, including basic nutrition knowledge, assessment, nutrition intervention, and dietary treatment of disease. However, nutrition education in medical schools has continued to fall below this target – and it’s getting worse. A 2012 survey4 found that most medical schools fail to require the recommended amount of nutrition education, with less than 15% of schools providing the 25-hour minimum. The number of hours devoted to nutrition education has dropped substantially since 2004, while the number of schools with no required nutrition education has risen4.

Compounding this issue, many medical training programs provide only basic nutrition background, often buried within a biochemistry or physiology course. While it is undeniably important to highlight the specific actions of vitamins and minerals, this model fails to highlight real-world clinical application of nutrition. Even less time is devoted to developing patient counseling skills. Lastly, the U.S.’s health professional training systems do not provide expertise or incentives to deliver effective counseling on how to achieve and maintain a healthy weight, diet, and physical activity level. This leads to a divide in thinking – a “should” or “want to do” versus “need to” or “have time to do”, and a reduced sense of urgency about implementing changes.

Working Toward a Solution

In addition to a lack of monetary or standard-of-care incentive to increase knowledge dissemination, another primary reason for suboptimal nutrition education is lack of time. This exists both in the amount of time devoted to actual coursework within medical training and for development of a nutrition curriculum within a program. Fortunately, several groups have worked diligently to provide resources that alleviate these barriers. In contrast to many programs that are specific to a particular institution, Nutrition in Medicine6, is a web-based series for students and healthcare professionals, administered through the University of North Carolina at Chapel Hill’s Department of Nutrition. There are over 40 modules ranging from 15 to 60 minutes in length that offer basic nutrition knowledge as well as evidence-based instruction of clinical skills. In addition to providing biochemical, clinical, and epidemiological components and virtual case studies, NIM also offers nutrition tools like pocket notes, nutrient recommendations, quizzes, and YouTube video vignettes. Nearly 75% of U.S. medical schools take advantage of at least one NIM module, and the program has proven to be successful in providing 33% more nutrition education in schools that use NIM versus those that do not.

And the best part? It’s completely free.

Future Directions

Despite the advances made by NIM in improving the dissemination of nutrition knowledge in the medical curriculum, challenges remain. Martin Kohlmeier, NIM’s principal investigator, has acknowledged that building good nutrition education tools is expensive and time consuming, since materials need to be reviewed continuously and updated every 4-5 years. Supporting a web-based tool takes a significant amount of resources, and funding sources are difficult to consistently maintain.

Recently, this cause has been taken up by several prominent health and medicine-focused organizations. A new effort has been launched to teach medical students, physicians, and other allied health professionals how to discuss obesity treatment and prevention options with patients. This initiative is a collaboration between the Bipartisan Policy Center, the Health and Medicine Division of the National Academies of Sciences, the American College of Sports Medicine, and the Alliance for a Healthier Generation. The multi-year project, supported by the Robert Wood Johnson Foundation, will develop “core competencies for obesity prevention, management, and treatment for the health professional training pipeline and identify payment policies that will incentivize the delivery of this care”, as stated in their April 11th press release7. Their goals are for these competencies to be implemented in training programs across the full spectrum of health professionals, and to determine a strategy to reimburse effective counseling for maintaining a healthy weight, diet, and physical activity level. “Training health professionals without a concurrent strategy to reimburse this type of care will not lead to meaningful change. And offering payment without having trained professionals to provide the care also will not result in improve[d] patient care,” the group stated.

This working group, like those involved in the Nutrition in Medicine curriculum, acknowledges that systemic changes to improve nutrition education in medical training will require continuous commitment from a wide range of stakeholders. Details of this initiative have not yet been announced, but those of us involved in education and clinical care certainly look forward to seeing the first steps begin.

Are you a health care professional, student, or educator? What is your experience in teaching or learning nutrition and nutrition counseling skills? I welcome your comments and insight on this issue.

References

1.Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html.

2.Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. Journal of Health Economics, 31(1): 219-230, 2012.

3.Rosen BS, Maddox PJ, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. Journal of Parenteral and Enteral Nutrition 2013;37(6):796–801.

4.Adams, K.M., Kohlmeier, M., & Zeisel, S.H. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic Medicine. 2010;85(9): 1537-1542.

5.Early KB, Adams KM, Kohlmeier M. Analysis of Nutrition Education in Osteopathic Medical Schools. Journal of Biomedical Education, vol. 2015, Article ID 376041, 6 pages, 2015. doi:10.1155/2015/376041

6.K. M.Adams, M.Kohlmeier, M. Powell, and S. H. Zeisel, “Nutrition in medicine: nutrition education for medical students and residents. Nutrition in Clinical Practice. 2010;25(5), 471–480. Available at: http://nutritioninmedicine.org/

7.Bipartisan Policy Center. New Effort Launch to Train Health Professionals in Nutrition and Physical Activity. http://bipartisanpolicy.org. 21 Mar. 2016.

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My Clinical Nutrition Internship Experience

By Seth Morrison

My name is Seth Morrison, a final year medical student at the Medical School for International Health in Israel. I would like to share with you a taste of my experiences in the ASN’s unique Clinical Nutrition Internship.

Clinical nutrition was never really on my radar as something I might become interested in until halfway through medical school. It was then that I attended the International Congress of Nutrition held in Granada, Spain, where I met some members of the ASN. Like most medical students, the nutrition content in my courses was only enough to whet my appetite. I never had a chance to really delve into nutrition in-depth so that I would feel comfortable counselling patients or speaking intelligently about it with colleagues. The ICN conference opened my eyes to the many different research branches of the nutrition sciences as well as public health nutrition. The global trends in the “double burden” of malnutrition (undernutrition and overnutrition) in developing countries began to worry me, and I started learning about the many efforts that are underway to intervene. All of this made me want to find an opportunity to supplement my nascent interest in nutrition, and see which career avenues exist. I would like to incorporate nutrition into my medical practice and possibly conduct public health nutrition interventions in resource-limited settings worldwide. That is when I discovered this clinical nutrition internship.

I think my internship was an unparalleled opportunity for a medical student to get an insider’s look into the fascinating world of clinical nutrition and nutrition science. The variety of opportunities I had at the University of Colorado and Children’s Hospital Colorado working with Dr. Nancy Krebs as my mentor gave me the ability to look at the role of nutrition in health from many different angles. I saw how important clinical nutrition is in the weekly outpatient clinics at Children’s Hospital. There were two separate clinics for kids with either growth faltering or obesity. These clinics are where I spent a great deal of my time. Throughout that time, I gradually gleaned the beauty in which skilled nutrition practitioners were able to make a real difference in outcomes as a team. Other physicians in these clinics, along with the amazing nutritionists, nurses, and a clinical psychologist, each contributed to my education in unique ways. They taught me the decision-making process of how to decipher clues to the causes of very different clinical nutrition problems (i.e. overweight vs. underweight), whether they be organic, lifestyle-related, or sometimes, in the case of young children, family food-related behaviors. This created the immensely enjoyable opportunity to decipher solutions to these myriad problems with clinical judgement and a creativity that respects the patient’s/family’s abilities and interests. I like to say today that in order to provide effective dietary counselling to patients, each doctor should have a little bit of a nutritionist inside them. This skill is one of the greatest gifts that the internship provided me for my own toolbox of clinical skills.

A sampling of the other components of my internship that made it very well-rounded were a research project, visits to WIC clinics, family eating well classes, several journal clubs and special nutrition lectures every week, and even a few nutrition-related Grand Rounds on Friday afternoons. I also completed a research project, which was a small metabolomics study on the relative serum levels of acylcarnitines and branched-chain amino acids in lean vs. obese groups of pregnant Guatemalan women.

This research component of the internship added an essential ingredient to the overall experience. Not only did I get to work with a fantastic and knowledgeable basic science researcher on a project in a burgeoning field of nutrition science (metabolomics), I also gained new skills and refined others that are needed in any research project I may become involved with in the future. This academic component reinforced the ever-present need for an army of researchers to inform the nutritional counsel given to patients in clinical medicine.

Inpatient care in the University of Colorado Hospital especially gave me the chance to see how crucial proper nutrition is for pre- and post-operative patients, burn unit patients, and of course in critical care. The nutrition support physician and the knowledgeable dietitians there broadened my knowledge of TPN and other topics in critical care nutrition research. In doing so, the truth was ingrained in me that nutrition is dynamic and can, in different circumstances, be prevention, treatment, or even both. Whether a patient is acutely ill or on a path of long term lifestyle change to reach a healthy weight, nutrition is likely to play an important role in their success!

The ASN Clinical Nutrition Internship satiated a special hunger for this nutrition niche in my medical education. I could not be more grateful and proud to have been awarded this unique opportunity, and the memories from it will linger with me for the rest of my career. As a soon-to-be physician, I’ve now learned that nutrition is a bit like music. It’s nice to listen to, but to really appreciate it, you must also learn to play some of your own notes.